Rhode Island Independent Insurance Agent - Revens-Gates, Inc. Insurance

401-294-9537

Homeowners Quote Form

To request a homeowners insurance quote, please complete the following form and click "Submit".

Personal Information:

Your Name: [required]

How would you like to be contacted?

Home Phone:

Work Phone:

Fax:

E-mail: [required]

Address of home to be insured:

Street Address Line 1: [required]

Street Address Line 2:

City: [required]

State:

Zip Code:

Is this home your primary residence? [required]

Yes No

Any rental apartments in the home?

Yes No

If yes, how many?

Amount of coverage on your home:

Amount of coverage on your home:[required]

Property deductible: [required]

Personal liabilty limit: [required]

Construction type: [required]

Approximate year home built: [required]

Smoke detectors? [required]

Yes No

Centrally monitored fire alarm? [required]

Yes No

Centrally monitored burglar alarm? [required]

Yes No

Number of claims in the past 3 years? [required]

Do you require special coverage riders for:

Jewelry?

		Amount
Yes	No

Furs?

Yes

Silverware?

Yes

Fine arts?

Yes

Boats, ATV's, Snowmobiles & other recreational vehicles?

Yes

Acknowledgements:

I hereby acknowledge that my submission of this form is for a price quotation and does not signify a contract between myself and Revens Gates Insurance or any of its insurance providers. Coverage is not in effect or bound until appropriate signed application has been received and approved.

I agree to the above terms and conditions. [required]

Thank you for your interest in our services. We will process your request as soon as possible and will contact you to confirm your quote.